In 1914, Congress passed the Harrison Anti-Narcotic Act to reduce the negative social and medical consequences associated with drug abuse. This law allowed the Federal government to regulate narcotic drug sales.

In 1939, the Assistant Surgeon General commented on the ensuing state of addiction treatment, noting that addicts who violated this Act “were at first sent to prison, where their real needs were neglected. They were treated there as prisoners deserving punishment rather than as patients who needed treatment. . . .The result was, too often, prompt relapse on discharge, with a vicious circle of other violations and prison confinements that continued the ruin started by narcotics.”

In recent decades, the number of adults involved in the criminal justice system has soared from about 1.8 million in 1980 to 7.3 million in 2007, due largely to prosecutions of drug-related crimes and drug-addicted offenders. Criminal offenders have rates of substance abuse and dependence that are more than four times that of the general population.

TODAY

Drug abuse and crime continue to be linked; and although addiction is recognized as a chronic, relapsing disease, offenders are still not getting the treatment they need.

Chronic drug abuse causes long-lasting brain changes that contribute to an addicted person’s compulsion to seek and use drugs despite catastrophic consequences. These brain changes persist long after drug abuse ends, leading to high rates of relapse (as with other chronic diseases) and the need for continuing treatment to help an individual achieve recovery.

More and better treatment is needed in the criminal justice system, and continuing through the period of re-entry into the community. It is estimated that about half of state and federal prisoners meet the criteria for drug abuse and dependence and yet fewer than 20 percent who need treatment receive it.

As in the general population, co-occurring substance use and other mental disorders are common, with about 45% of inmates in local jails and State prisons having both. In addition, about 75% of inmates with a mental illness also meet criteria for substance abuse, and vice-versa. This high rate of co-occurrence underscores the need for offenders, both adults and juveniles, suffering from one disorder to be screened for the other and, where appropriate, treated for both, necessitating an integrated treatment approach.

Involvement in the criminal justice system provides an opportunity to diagnose and treat these health problems, which also include infectious diseases like HIV. Fourteen percent of HIV-infected individuals pass through correctional facilities each year, and yet criminal justice–based services and community health and social services remain fragmented.

Treatment works, is cost-effective, and can help end the vicious cycle of drug abuse and criminal recidivism.

Research demonstrates that treatment can work for drug abusing offenders, even when it is entered involuntarily. Forced abstinence (when it occurs) during incarceration is not equivalent to treatment. Failure to receive needed treatment or access to services often leads to relapse and re-arrest, usually during the first 12 months after release.

Juvenile Offenders: Virtually every juvenile offender should be screened for drug abuse and mental disorders, and receive an intervention:

Treatment for those who are dependent on alcohol or drugs, or mentally ill.

Drug abuse prevention for those who are not.

HIV prevention or treatment as needed.

Longitudinal studies show that treatment begun in the criminal justice system and continued in the community garners lasting reductions in criminal activity and drug abuse. This includes medication-assisted treatment (i.e., methadone) for prisoners with heroin addiction (see figure below).

Providing treatment is cost-effective, saving between $2 and $6 for every $1 spent on it, which in part reflects reductions in criminal behavior and re-incarceration.

TOMORROW

Getting proven treatments into the criminal justice system will promote abstinence, help identify and mitigate related diseases like HIV, and foster productive reintegration back into the community.

Working together, public health and criminal justice systems will make evidence-based treatments, including medications, available to the offender population—an effort being promoted through a NIDA-led multisite, interagency research initiative known as CJ-DATS—Criminal Justice Drug Abuse Treatment Studies (http://www.cjdats.org/Wiki%20Pages/Home.aspx). CJ-DATS seeks to test proven treatments and implementation strategies within the criminal justice system and remove the barriers to their adoption.

Novel medications to enhance recovery for drug-addicted offenders will include “depot medications,” or long-acting varieties for opiate and other addictions. With effects that last for weeks instead of hours, depot formulations promote adherence because patients do not need to motivate themselves daily to stick to a treatment regimen. And since there are no take-home daily medications, the potential for diversion and abuse is reduced. Depot naltrexone (marketed as Vivitrol for alcoholism), was recently approved by the FDA for heroin addiction. Ongoing research also aims to develop a long-acting version of buprenorphine, as well as addiction "vaccines” able to make antibodies that bind to specific drugs in the bloodstream preventing their entry into the brain—with effects that can last for months. Vaccines to counter cocaine, methamphetamine, and heroin abuse are under study.

The overrepresentation of both drug abuse and HIV within criminal justice populations demands better strategies to integrate services and improve outcomes for both. A novel approach known as “seek, test, treat” aims to reach out to high-risk, hard-to-reach groups who have not been recently tested, test them for HIV, and initiate and maintain HAART (highly active antiretroviral therapy) for those testing positive. Prison settings offer a good opportunity to integrate substance use treatment with early HIV diagnosis and treatment initiation and will be a fertile testing ground for this innovative strategy with, to include reliable maintenance of treatment in the community.